Category Archives: The Broken System

It cost the government $100 million to float the company. Brokerage fees and various sundries totalled more money than I will ever see in my life.

Meanwhile, I am waiting for a bed in respite care. I live in a hospital area that serves 140,000 people. One in five of us will suffer mental illness – so that’s 28,000 people. And catering for this area is one emergency respite care house. With three beds.

So my country can justify selling off a state asset, that’s making the country money, and running up a hundred million dollar bill while doing it – but they give my District Health Board enough funding for THREE respite beds.

I’m not the worst off though – that award would go to Mid-Central DHB, which serves 158,000 people, and has precisely no adult respite beds. It’s the ward or nothing there.

Mental health is woefully underfunded. I can guarantee that very little of the one-time $1.7b capital raised by the sale of Mighty River will come our way. But a fragment of the hundred million it cost would make a huge difference to mental health patients and workers.

The mental health system is struggling under the burdens of understaffing, lack of facilities, and a broken model. What does this mean for those in crisis?

From painful experience, it means that even those in moderate to severe distress are sent home. Sent home to deal with the voices in their heads, the suicidal urges, the creeping loss of control, often alone and unsupported.

A suicide attempt is often sent home from the emergency department as soon as they’re stable enough, because ‘you’re not sick enough for the ward’. Presenting at the hospital before you get that far can result in many hours in a soothing blue room before being told there’s no space. Hearing voices telling you to kill can be dismissed as ‘not common with your diagnosis’. All because there is no space for any but the violently unwell.

It’s broken. It makes me sad. But more than that it makes me angry. We’re failing the vulnerable, and it’s slowly killing them.

Forty years ago, the seriously mentally ill were put into long-term facilities. These places have all closed down, much to the relief of many who were abused in them. In place of these institutions the system follows the ‘community model’.

The community model sounds like a good idea – keeping the mentally ill in their own homes to reduce stigma and encourage normal lifestyles. But the idea is badly flawed. The severely mentally ill often cannot care for themselves.

With these very unwell patients, two options develop. One is that they are committed to inpatient care in the acute hospital units. When I was last in there some of the patients had been there a year or more – in the places meant for urgent, acute need.

The second option is that their long-suffering families care for them. This can be intense, and is often difficult, as the family realise that their loved one is severely unwell and needs constant care. It puts the family under a lot of strain, but they’re the only thing standing between their loved one and the rarely-acknowledged third option: falling through the cracks. This has the potential to end in tragedy.

The old system was badly flawed. It was rife with abuse, and it didn’t fit the needs of many mental health patients. However, the new system is equally flawed, and it is failing many mental health patients as well. Maybe a combination of both would be better.

One of the most important things for many psych patients is the relationships they form with their mental health workers. These relationships are part of their therapy in a way, as they learn to trust the people trying to help them. And it’s an area that the NZ system fails in.

The fragmentation of the system – the separation of crisis management, community mental health, and acute inpatient care – makes continuity difficult. A patient starts to trust the crisis team, but they’re handed off to the community team. Then, if they get very unwell and are put into the ward, they see yet another team. Every time the care team changes, history has to be taken again, trust has to be built, and an often already battered patient has to jump through new hoops. It can be frustrating and demoralising.

Staff inconsistency also contributes to a lack of continuity – not only does scheduled time off require different workers for periods of time, but the rapid burnout of mental health workers means that a patient can be shuffled around fairly often.

The therapeutic relationship is so important for so many psych patients, and to have it disturbed so often is detrimental to these vulnerable.

The NZ mental health system is a hell of a lot better than many other countries, I’ll admit – it exists, and it’s free. But it has some massive problems that let some very unwell people fall through the cracks.

The system is madly understaffed, and the staff are madly overworked.

Most psychiatrists are part time, working only one or two days a week, and filling the rest of their time in the private or educational sectors. This creates heavy demand for the few appointments they have available – appointment times which are shortened by the need to document everything. This leads to an uncomfortable rush for most patients.

The less-exalted members of the mental health team – nurses, social workers, therapists and so on – are no less rushed. Their case loads are far above what they can realistically handle, because there are not enough staff to cover the caseload. At one stage in my treatment I was supposed to see a social worker, but there were none available, so I was assigned to an occupational therapist simply because she had a slot for me. This sort of thing is rampant, and it leads to suboptimal care for the patient, and a suboptimal work environment for the staff.

Burnout rates are high. While I don’t have any hard data, in my experience many staff burn out within a couple of years. This is rough on the staff member, but also on the patient who has formed a relationship with ‘their’ worker.

It’s a system trying to do too much with too little, and it’s not good enough. Mental health patients deserve better. Mental health workers deserve better. But we’re downtrodden enough to let it slide.

The NZ public mental health system is a confusing beast, so before I write on what’s wrong with it, I’ll give a quick overview of how it works.

Mental health emergency lines are the absolute front line of mental health treatment. People in crisis call these lines, and the poor soul on the other end get to prise adequate information out of the caller and work out what services they need, all the while trying to keep the caller safe. This sometimes involves sending out the police or an ambulance if they believe there is real danger to the caller. In less urgent circumstances, this usually involves referral to the mental health emergency team.

The emergency mental health team is many people’s first true contact with ‘the system’. It goes by many names, usually incorporating the words ‘crisis’ or ’emergency’. It’s the equivalent of the emergency department for physical medicine.

A mental health emergency team usually has a handful of mental health nurses (at least two on duty at any given time), a couple of psychiatrists (one on call at all times, plus one or two holding a few office hours during the week), and an administrator. The nurses are the core of the team’s operations, making home visits to people in crisis, assessing those who have presented at the emergency department, and co-ordinating with the psychiatrists on the team to get people seen, and with the inpatient unit for severe crises. Treatment with the emergency team will usually last for about a month – long enough to get someone stabilised, or to get them their first appointment at Community Mental Health.

Community Mental Health is the workhorse of the mental health system. It’s made up of psychiatrists, psychologists, mental health nurses, social workers, occupational therapists, counselors and probably a few things I’ve forgotten. They’re responsible for everyday non-urgent mental health care. When a person is referred to community mental health, they’re assigned a case manager to co-ordinate their care.

The final element in the system is the inpatient unit. Inpatient units are far less common than they were thirty years ago, but they still exist. They’re usually divided into two parts – inpatient and intensive care. Both sections are designed strictly for short stays – a few months at most. The services offered are varied – sometimes there is therapy and activities, but sometimes there is just medication and a weekly review by a psychiatrist

So there’s the outline of the system. Tomorrow I’ll start on what’s wrong with it.